Nursing Elites

1. A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?

• A. Restrain the client in bed
• B. Ask a family member to stay with the client
• C. Check the client every 15 minutes
• D. Use a bed exit safety monitoring device

Correct answer: D

Rationale: Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.

2. When reviewing the demographics of ethnic groups in the United States, which group does the nurse recall as the largest and fastest-growing population?

• A. Asian
• B. Hispanic
• C. American Indian
• D. African American/Black

Correct answer: B

Rationale: The correct answer is 'Hispanic.' Hispanics are the largest and fastest-growing population in the United States. While African Americans/Blacks, Asians, American Indians, and other groups are significant, Hispanics currently represent the largest demographic group. African American/Black, Asian, and American Indian populations are substantial but not as large or fast-growing as the Hispanic population. Therefore, Hispanic is the most appropriate choice in this scenario.

3. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?

• A. Collaborating with the client to establish healthcare goals
• B. Reviewing the client's medical record history
• C. Explaining the purpose of administered medications to the client
• D. Rapidly resetting priorities for client care based on changes in the client's condition

Correct answer: D

Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.

4. The client reports nausea and constipation. Which of the following would be the priority nursing action?

• A. Collect a stool sample
• B. Complete an abdominal assessment
• C. Administer an anti-nausea medication
• D. Notify the physician

Correct answer: B

Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.

5. When is a physician likely to assess turgor?

• A. When iron deficiency is suspected.
• B. When heart and lung issues are suspected.
• C. When dehydration is suspected.
• D. None of the above.

Correct answer: C

Rationale: Skin turgor is assessed when dehydration is suspected. To evaluate skin turgor, a physician pinches the skin and observes how quickly it returns to its normal position. If the skin stays folded for an extended period, it indicates dehydration. Assessing turgor helps determine a patient's hydration status. Choice A is incorrect because skin turgor is not used to assess iron deficiency. Choice B is incorrect as turgor is not related to heart and lung issues, but rather hydration status. Choice D is incorrect as turgor assessment is relevant when dehydration is suspected.

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